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Challenges to Improving Safety at the Point of Care Building Infrastructure

Slide presentation from the AHRQ 2008 conference showcasing Agency research and projects.

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Katherine Jones and Team, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.5 MB).

Slide 1

Challenges to Improving Safety at the Point of Care

Building Infrastructure: Lessons Learned from Critical Access Hospitals
AHRQ Annual Meeting
Sept. 9, 2008
Katherine Jones, PT, PhD
And Team.

Supported by AHRQ Grant 1 U18 HS015822
AHRQ Knowledge Transfer
National Rural Health Association
Nebraska Department of HHS.

Slide 2


  • Knowledge: Patient safety infrastructure requires common knowledge of a theoretical framework to achieve sensemaking.
  • Skill: Assess culture and implement change; comply with Joint Commission Leadership Standards (LD.03.01.01).
  • Attitude: Believe that key safety culture practices create the infrastructure that organizations must use to support frontline workers who improve quality and keep patients safe.

Slide 3

Critical Access Hospitals (CAHs)

The map of the United States shows the "Location of Critical Access Hospitals."

  • Limited to:
    • 25 inpatient beds.
    • 96 hour average length of stay.
  • Receive cost-based reimbursement to maintain access to care in rural areas.
  • 1,289 CAHs concentrated in Midwest; ¼ of general community hospitals in U.S.

Slide 4

What does a CAH look like?

The slide shows a portion of Route 80 in Nebraska and two colored photographs, one of Dundy County Hospital in Benkelman, NE, and one of the wide-opened area surrounding it.

Slide 5

Chain of Impact at the Point of Care

The flowchart shows the structuring and processes that impact quality at Point of Care.

  • Healthcare System, Structures, & Processes.
  • Organizational Structures & Processes.
  • Culture.
  • Individual Provider Structures & Processes.
  • Quality at Point of Care:
    • Influenced by Interpersonal Care.
    • Influenced by Technical Care.
  • The quality, safety and value of care can be no better than the structures and processes used by providers in direct contact with the patient. Culture determines how organizations support providers at the point of care.
  • Note: Nelson et al. (2002) Joint Commission Journal on Quality Improvement 28, 472-93.
  • Note: Swuste P. (2008). Human Factors and Ergonomics in Manufacturing 18, 438-53.

Slide 6

How can organizations effectively support providers at the point of care?

  • AHRQ-supported research with Critical Access Hospitals (CAHs) provides evidence consistent with Dr. Clancy's message: "How to translate research into improvement:"
    • Infrastructure.
    • Capacity.
    • Incentives.
  • Implementing a Program of Patient Safety in Small Rural Hospitals.
  • Evaluating the Effect of TeamSTEPPS tm Training on the Culture of Safety in Critical Access Hospitals.

Slide 7

Implementing a Program of Patient Safety in Small Rural Hospitals

  • One of 17 AHRQ Partnerships in Implementing Patient Safety (PIPS) grants funded 7/05—6/07 (AHRQ Grant 1 U18 HS015822).
  • Purpose: To implement the patient safety practices of voluntary medication error reporting and organizational learning in 24 Critical Access Hospitals.
  • Aim 1: Develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error.

Slide 8

Evaluating the Effect of TeamSTEPPS tm Training on the Culture of Safety in Critical Access Hospitals

  • Funding through AHRQ and Nebraska Department of Health and Human Services (DHHS).
  • Purpose: To implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals.
  • Aim 1: Evaluate the impact of the TeamSTEPPS training program on safety culture using the rural-adapted version of the AHRQ Hospital Survey on Patient Safety Culture.

Slide 9

The Components of an Effective Patient Safety System*

The flowchart shows the process evaluation of AHRQ's patient safety research by identifying the five system components that interact to improve practices and increase patient safety at the point of care.

  • The components are:
    1. Monitoring progress/maintaining vigilance.
    2. Knowledge of epidemiology of patient safety risks and hazards.
    3. Development of effective practices and tools.
    4. Building infrastructure for effective practices, and
    5. Achieving broader adoption of effective practices.
  • Note:  *Farley DO, Damberg CL, Ridgely MS, et al. Assessment of the AHRQ patient safety initiative final report—Evaluation report IV. Rand
    Organization; 2008 Technical Report No. 563.

Slide 10

Phase One: Reporting in an Effective Patient Safety System

The flowchart examines the phase one research cycle.

  • Four CAHs in Nebraska sought help from UNMC to make sense of their medication errors.
    1. Understand the epidemiology of medication errors.
    2. Develop effective tools: process maps, reporting forms, database.
    3. Monitor progress: benchmarking reports and assistance to manage process change.
    4. AHRQ funding supported an infrastructure—subscriptions to MEDMARX,, education about disclosure of errors, just culture, root cause analysis.
    5. AHRQ funding enabled broader adoption of these practices across 35 CAHs in three states.

Slide 11

Sensemaking Tools From PIPS Grant: Process Map, Reporting Form

The slide presents both an extensive flowchart which maps out the steps nurses need to take in prescribing; documentation and order processing; preparation and dispensing; and administration of medication, and an image of a "Medication Safety Reporting Form."

Slide 12

Sensemaking Tools from PIPS Grant: Transform Data into Information

The slide presents both a screen shot of the homepage from Medmarx's Web site and a pie chart on "Error Severity, Jan.-June 2007 (31 CAHs submitted 2,799 reports)."

  • Pie Chart Data:
    • A (potential error): 28%
    • B (near-miss): 20%
    • C (reaches pt, no harm): 50%
    • D (reaches pt, monitoring): 2%
    • E (temporary harm): 0%
    • F (harm, hospitalization): 0%

Slide 13

Phase Two: Assessing Progress in an Effective Patient Safety System

The flowchart examines the phase two research cycle.

  • Second action research cycle of our PIPS Grant.
    1. Knowledge that reporting is the foundation of a culture of safety; working definition.
    2. Need an effective tool to assess culture.
    3. Monitor progress and assess change in culture due to reporting infrastructure.
    4. Build rural quality improvement infrastructure by adapting HSOPS to the rural environment.
    5. Achieved broader adoption of rural-adapted version of HSOPS by disseminating it to QIOs and contracting with the National Rural Health Association.

Slide 14

Working Definition of Safety Culture

  • Enduring, shared beliefs and behaviors that reflect an organization's willingness to learn from errors*
  • Three beliefs present in a safe, informed culture**
    • Our processes are designed to prevent failure.
    • We are committed to detect and learn from error.
    • We have a just culture that disciplines based on risk.

Slide 15

What are the Components of Safety Culture?

  • Reporting—staff report their errors.
  • Just—reporting is rewarded, clear line between acceptable & unacceptable behavior.
  • Flexible—authority patterns relax when safety information is exchanged.
  • Learning—action is taken based on safety information systems.

An image of a pyramid appears to emphasize the process: (from bottom to top)

  • Reporting.
  • Just.
  • Flexible.
  • Learning.
  • Informed = Safe
  • Note: Reason, J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.

Slide 16

How Can Organizations Effectively Support Providers at the Point of Care?

  • Use the AHRQ Hospital Survey on Patient Safety Culture (HSOSPS) to identify and monitor impairments in organizational learning at the level of units/departments and staff positions.
  • Implement effective practices within each of the four components of a safe culture that address impairments within microsystems.
  • Ensure interactions between the practices to engineer an infrastructure—a culture—that supports organizational learning.

Slide 17

How Does HSOPS Identify Impairments in Organizational Learning?

  • HOSPS measures staff perceptions of the beliefs and behaviors that support a safe culture.
  • HSOPS is a valid, reliable instrument comprised of 51 items categorized in 12 dimensions.
  • 12 dimensions reflect the four components of an informed, safe culture.
  • A tool to evaluate, plan, reevaluate patient safety programs.
  • Small rural hospitals require support to use it effectively.
  • Note: Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12 (Suppl II), ii17-ii23.
  • Note: Jones, Skinner, Xu, Sun, Mueller. The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. In Henriksen et al., Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign . AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.

Slide 18

Benchmark HSOPS Graph of Aggregate Hospital Results

The line graph shows the "Comparison of Positive Composite Survey Results to Peer Group Minimum and Maximum."

  • Survey topics:
    • Overall perception of safety.
    • Frequency of events.
    • Reported manager actions promoting patient safety.
    • Organizational Learning.
    • Teamwork within departments.
    • Communication openness.
    • Feedback and communication about error.
    • Nonpunitive response to error.
    • Staffing.
    • Hospital management support for safety.
    • Teamwork across hospital departments.
    • Hospital handoffs and transitions.

Slide 19

HSOPS Graph Comparing Nurse to Aggregate Hospital Results

The line graph shows the "Comparison of Positive Hospital Composite Survey Results to Nurse and Non-Nurse Results."

Slide 20

Benchmark HSOPS Graph of Aggregate Results 2005 and 2007

The line graph shows the "Safety Culture Survey Composite for Dundy County Hospital."

Slide 21

Interactions Between Components

The table is divided into four columns: "HSOPS Items: Nurses at Dundy County Hospital 2005 and 2007," "%+ 2005," "%+ 2007," and "Effective Practices."

  • Outcome: Our procedures, systems are good at preventing errors.
    • 31%
    • 3%
    • High Reliability Organization.
  • Learning: We are given feedback about changes put into place based on event reports.
    • 44%
    • 72%
    • QI, RCA, Leadership Walkrounds™, Safety Briefings.
  • Flexible: Staff feel free to question the decisions and actions of those with more authority.
    • 13%
    • 50%
    • Structured Communication skills: SBAR, CUS, DESC.
  • Just: When an event is reported, it feels like the person is being reported and not the problem.
    • 31%
    • 50%
    • Education about human error, Unsafe Acts Algorithm.
  • Reporting: When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported.
    • 25%
    • 65%
    • Systematic reporting system using standard taxonomies.

Slide 22

Execute Just Culture . . . UNSAFE ACTS ALGORITHM

The detailed chart goes through and shows culpable, gray area, and blameless instances in patient safety.

Slide 23

Phase Three: Integrating Team Training in an Effective Patient Safety System

The flowchart examines the phase three research cycle.

  • Third action research cycle.
    1. Knowledge that a culture of safety in high reliability organizations is engineered from interacting practices of the four components of culture within microsystems (units/positions).
    2. HSOPS results indicated the need for training in teamwork and communication.
    3. We conducted the train the trainer course in 25 CAHs in April 2008; will add 7 more in 2009.
    4. We are building a community of TeamSTEPPS coaches/trainers across the state.
    5. We will reassess safety culture in 25 CAHs in March 2009.

Slide 24

HSOPS Identifies Readiness for Teamwork Training

  • TeamSTEPPS training must be supported by systematic error reporting, just culture practices, and use of learning tools such as individual and aggregate RCA, Leadership WalkRounds, and Safety Briefings.
  • The diagram presents the three phases as a complete process.
  • PHASE I: Assessment.
    • Pre-Training Assessment.
      • Site Assessment.
      • Culture Survey.
      • Data/Measures.
    • Leads to Readiness/Climate Improvement.
    • Action Plan.
  • PHASE II: Planning, Training and Implementation.
    • Training.
      • Intervention.
      • Test.
  • PHASE III: Sustainment.
    • Culture Change.
      • Coach and Integrate.
      • Monitor the Plan.
      • Continuous Improvement.
  • Set the Stage, Decide What to Do, Make it Happen, Make it Stick.

Slide 25

Conclusion: Infrastructure for Effective Practices

The image of the pyramid with the process of "Reporting, Just, Flexible, Learning, Informed = Safe = HRO" and "Sensemaking Trust."

  • Interaction between effective practices results in sensemaking within macro- and microsystems of care.
  • Sensemaking requires data, which is interpreted within the context of the lived experiences of those in direct contact with patients.
  • Sensemaking can not occur without data from reporting, trust and teamwork.

Slide 26

Infrastructure: Lessons Learned from Dundy County, Nebraska

The colored photograph shows two women standing in front of the Dundy County Hospital.

  • "Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn't heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them."


  • (pop. 2,109).
  • James Reason has a quote: Learning disabilities.

Slide 27

Rural Adaptation of HSOPS

  • Original HSOPS designed for large urban hospitals—1/3 in national database choose "other."
    • 14 different work areas.
    • 14 different staff positions.
    • Sort by work area or position if ≥ 11.
  • Rural—adapted HSOPS for hospitals with ≤ 50 beds.
    • 12 different work areas—12% choose "other."
      • Collapsed multiple departments to Acute/Skilled Care.
      • Added Long-term care, Home Health Care, Therapies.
    • 6 different job titles—8% choose "other."
    • Sort by work area or job title if ≥ 5.

Slide 28

Rural Adaptation of HSOPS

  • Original AHRQ HSOPS Work Area Demographics
    • Shows Section A of the survey, "Your Work Area/Unit" which asks "What is your primary work area or unit in this hospital?"
    • 2008 Comparative Database Report: 33% of 160,196 respondents choose "other."
    • Rural-Adapted HSOPS Work Area Demographics.
    • Shows Section A of the survey, "Your Department" which asks "What primary department do you work in at this hospital?"
    • UNMC CAH Comparative Database: 12% of 4,117 respondents choose "other."

Slide 29

Rural Adaptation of HSOPS

  • Original AHRQ HSOPS Staff Position Demographics.
    • Shows a portion of the survey with a question asking "What is your staff position in this hospital?"
    • 2008 Comparative Database Report: 22% of 160,196 respondents choose "other."
  • Rural-Adapted HSOPS Staff Position Demographics.
    • Shows a portion of the survey asking for the individual to "Check one answer that best describes your position."
    • UNMC CAH Comparative Database: 8% of 4,117 respondents choose "other."

Slide 30

Where can I get the HSOPS?

Slide 31

Contact Information

Page last reviewed February 2009
Internet Citation: Challenges to Improving Safety at the Point of Care Building Infrastructure. February 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


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